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NIV for COPD exacerbation

Citation/s:
Laurent Brochard, Jordi Mancebo et al: Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. NEJM 1995; 333:817-22

Lead author's name and fax: Laurent Brochard

Three-part Clinical Question: In patients with COPD exacerbations, does the use of non-invasive ventilation reduce the incidence of ventilator associated pneumonia?

Search Terms: NIV, VAP, COPD.

The Study: Non-blinded randomised controlled trial with intention-to-treat.

The Study Patients: Adult patients admitted to 5 French ITUS over 15 months with known COPD, or a high probability of COPD, with an exacerbation of dyspnoea accompanied by at least 2 of the following: RR>30, PaO2< 45mmHg, pH

Control group (N = 42; 42 analysed): Standard treatment - oxygen to a max flow rate of 5l/min in order to achieve Sa02>90, SC heparin, antibiotics, bronchodilators, steroids, aminophylline. Intubation was performed on the presence of specific criteria.

Experimental group (N = 43; 43 analysed): The same medications as above with the addition of periods of NIV for at least 6 hours a day. All patients breathed spontaneously for at least 2 hours per day. The exact duration and pattern of NIV was determined by the attending physician. Pressure support was initially 20cm. Oxygen was administered to achieve SaO2>90. Intubation criteria were similar to control.

The Evidence:

Comments:
Do the methods allow accurate testing of the hypothesis? There is no information as to how sample size was determined. The limitation in oxygen flow in the control group to 5l/min may have made intubation for hypoxia more likely in this group, although hypoxia alone was not an indication for intubation.
Do the statistical tests correctly test the results to allow differentiation of statistically significant results? Yes
Are the conclusions valid in light of the results? Probably
Did results get omitted, and why? No
Did they suggest areas for further research? No - A further study would be required to give a more definitive answer to the question posed.
Did they make any recommendations based on the results and where they appropriate? No
Is the study relevant to my clinical practice? Yes
What level of evidence does this study represent? Level 1⁺

What grade of recommendation can I make on this result alone? B
What grade of recommendation  can I make when this study is considered along with other available evidence? N/A - single study in this patient group (with VAP as an outcome).
Should I change my practice because of these results? Yes - the potential for benefit is great and the potential for harm small, as long as NIV is carried out appropriately.
Should I audit my current practice because of these results? Yes - audit the use of NIV in COPD patients, and thei subsequent intubation rate.

Appraised by: B Miles; 20 May 2004

Email: barbara.miles.stob@northglasgow.scot.nhs.uk

Kill or Update By: May 20066

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